Optometry & Visual Performance 287 Volume 13 | Issue 4 | December 2025 Feature Superior Oblique Palsy Inferior Oblique Overaction Hypertropia Present in the affected eye, worse in adduction and when looking down. Worse in adduction, but often bilateral and symmetric accompanied by infantile strabismus. Gaze Dependence More pronounced in adduction / contralateral gaze (e.g., right SOP worsens in left gaze) and when looking down (e.g., reading position); often associated with V-pattern strabismus. More pronounced in adduction / contralateral gaze and when looking down; often associated with V-pattern strabismus (same as SOP) Head Posture Compensatory head tilt to the opposite shoulder (e.g., left tilt for right SOP) to minimize double vision. Hypertropia worsens when the head is tilted toward the affected side (positive Bielschowsky test). Head tilt is less common; may occur to compensate for associated horizontal esotropia. Bielschowsky head tilt test typically negative. Torsion Excyclotorsion present due to unopposed inferior oblique action. Excyclotorsion may be present, but less pronounced unless severe; often bilateral in infantile strabismus. Laterality Usually unilateral in congenital SOP; bilateral in ~15% of cases (often post-traumatic). Often bilateral in infantile strabismus, though one side may predominate. Associated Conditions May occur in isolation or with cranial nerve palsies; congenital cases often linked to abnormal superior oblique tendon. Commonly associated with infantile esotropia or dissociated vertical deviation (DVD); rarely isolated.
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